Educational Pearls: Tiflitis refers to the presence of enterocolitis in the setting of neutropenia - also known as neutropenic enterocolitis Commonly a result of chemotherapy for hematologic malignancies. The infection is usually polymicrobial/fungal and can lead to septic shock Usually presents with fever, abdominal pain, with associated GI complaints Workup includes CBC for the ANC (usually Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents Mortality can be ...
May 14, 2019•3 min
Author: Erik Verzemnieks, MD Educational Pearls: Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord Trauma, infection, hematoma, disc rupture/herniation can cause this - basically anything that can cause pressure and fill space Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation Post-void residual that is abnormally high may be an indicator MRI is diagnostic modality of cho...
May 09, 2019•3 min
Author: Nicholas Hatch, MD Educational Pearls: Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection SSPE is a central nervous system disease that has no cure and is nearly universally fatal Educating patients on the importance of vaccination should include discussion of these long term consequence...
May 06, 2019•4 min
Author: Ryan Circh, MD Educational Pearls: The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation Capillary refill time was standardized (this is not straightforward): A glass microscope slide was pressed on the ventral side of the right index finger Pressure was increased until the skin was blanched This pressure was sustained for another 10 seconds After pressure was removed, the time to return to normal skin ...
May 05, 2019•3 min
Author: Aaron Lessen, MD Educational Pearls: A problem of take-home-naloxone is the administration of it by an able-bodied bystander Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present Half of those in the presence of others had a bystander that was not impaired Take-h...
May 02, 2019•2 min
Author: Erik Verzemnieks, MD Educational Pearls: Buproprion is used as an antidepressant and for smoking cessation Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias Benzodiazepines are treatment of choice for seizures Bicarbonate and Interlipid are also possible treatment options with less evidence References Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361;...
Apr 30, 2019•2 min
Author: Don Stader, MD Educational Pearls: 10% of patients seen in the emergency department for opioid overdose patients will die within a year Half of these overdoses will occur in the next month This mortality rate is higher than patients with STEMI, of which 7% will die within one year Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives References Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. J...
Apr 27, 2019•3 min
Author: Gretchen Hinson, MD Educational Pearls: Breath stacking occurs when a patient is unable to expire fully before another inspiration In intubated/ventilated patients, this is because adequate time has not passed before exhalation Asthmatics are susceptible due to the prolonged expiratory phase Complications can include reduction in cardiac preload and cardiovascular collapse Pursed-lip breathing can help in the spontaneously breathing patient Intubation may be required when patients presen...
Apr 24, 2019•6 min
Author: Michael Hunt, MD Educational Pearls: Most causes of syncope are benign Pulmonary embolism can result in syncope and is life threatening A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up PE should always be considered in cases of syncope but overall is a rare cause Editor's note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope - whic...
Apr 22, 2019•3 min
Author: Julian Orenstein, MD Educational Pearls: Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia) Respiratory depression requiring intubation is not uncommon References Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016....
Apr 20, 2019•3 min
Author: Nick Hatch, MD Educational Pearls: A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates) References Subramaniam B, Shankar P, Shaefi S, Mueller A, O'Gara B, Banner-Goodspeed V, Gallaghe...
Apr 17, 2019•3 min
Author: Jared Scott, MD Educational Pearls: Modified Rankin Score: measure of disability often used to qualify outcomes following stroke = no disability, 6=dead, 0-1 indicate good outcome) 0-6 Scale 0-1 indicative of good outcome ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia 0-10 Scale 10 areas are assessed on non-contrast CT to assess for early stroke changes -1 for each area with these findings 8-10 is indicative of better outcomes References Aviv RI, Man...
Apr 15, 2019•4 min
Author: Jared Scott, MD Educational Pearls: Beta-blockers can mask the effects of hypoglycemia Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon Octreotide can be used as an antidote with sulfonylurea ingestion Editor's note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another ...
Apr 12, 2019•4 min
Author: Michael Hunt, MD Educational Pearls: Like all tests, urine toxicology (utox) screens can have false positives Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP Over-the-counter medication such as dextromethorphan also mimic PCP on utox References Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits . Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/Janu...
Apr 11, 2019•4 min
Educational Pearls: Acetaminophen overdose can also present in patients taking too much over the course of days to weeks - not just intentional ingestions If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level In chronic overdose, Tylenol levels will not guide treatment NAPQI is the toxic metabolite of acetaminophen N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses 7.5 g is the da...
Apr 09, 2019•5 min
Author: Sam Killian, MD Educational Pearls: Headache is a common complaint in the ED. It's plausible that headaches could be correlated with environmental factors A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution References: Yilmaz M, Gurger M, Atescelik M, Y...
Apr 04, 2019•3 min
Author: Sam Killian, MD Educational Pearls: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals The disease is caused by a defect in the NOTCH3 gene on chromosome 19 It is an important cause of stroke in young patients Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy Migraine with aura is often the first presenting symptom with onse...
Apr 01, 2019•4 min
Author: Don Stader, MD Educational Pearls: Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as e...
Mar 29, 2019•4 min
Author: Sam Killian, MD Educational Pearls: Viral gastroenteritis alters the gut microbiome and it is theorized that probiotics may help reduce the duration and severity of the disease. Double-blind randomized controlled trial involving almost 900 children with viral gastroenteritis compared 5 days of probiotics to a control group. There was no difference in the rates of severe gastroenteritis between the two groups Probiotics are likely unhelpful for kid with viral gastroenteritis References: F...
Mar 27, 2019•2 min
Author: Dylan Luyten, MD Educational Pearls: A "banana bag" is a bag of IV fluid that contains various vitamins and minerals including folate and thiamine IV fluids do not alter intoxicated patients recovery in the emergency department Folate deficiency is rare in the intoxicated patient Some intoxicated patients may be thiamine deficient, and those that would benefit the most need significantly more daily thiamine supplementation than provided in a banana bag References: Perez SR, Keijzers G, S...
Mar 25, 2019•6 min
Author: Ryan Circh, MD Educational Pearls: Chronic salicylate (ASA) toxicity can present in elderly patients as altered mental status Consider chronic toxicity in patients with an unexplained anion gap acidosis Treatment for chronic ingestion typically includes IV fluids and urine alkalinization References: O'Malley GF. Emergency department management of the salicylate-poisoned patient. Emerg Med Clin North Am. 2007 May;25(2):333-46; abstract viii. Review. PubMed PMID: 17482023. Durnas C, Cusack...
Mar 23, 2019•3 min
Author: Dylan Luyten, MD Educational Pearls: Recent randomized controlled trial compared intravenous to oral acetaminophen in emergency department patients There was no difference in pain relief between the groups While the actual acquisition cost of these drugs are not significant, the cost multipliers that are passed onto patients lead to real dollars With the significant cost of IV acetaminophen, it may not be the best choice given the lack of superiority to other formulations References: Fur...
Mar 20, 2019•3 min
Author: Dylan Luyten, MD Educational Pearls: 1:500 patients will experience a retinal detachment Consider stroke on your differential (central retinal arterial occlusion) Flashes and floaters are a common complaint with retinal detachments Though patients may report fields of vision loss, visual acuity is often spared Ocular ultrasound is an effective way to diagnosis retinal detachment in the ED These require urgent ophthalmologic consultation for surgical repair References: https://www.aliem.c...
Mar 19, 2019•6 min
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Mar 11, 2019•17 min
Author: Michael Hunt, MD Educational Pearls: Bedside transtracheal ultrasound to confirm proper endotracheal intubation is simple and effective Review of 17 studies showed transtracheal ultrasound was was 98.7% sensitive and 97.1% specific Curvilinear probe may be preferable as it provides a larger field of view Editor's Note: rather than explain what you're looking for… just go here References: Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubatio...
Mar 08, 2019•3 min
